Recently, a hospital in the Central California city of Fresno was fined $86,000 for a medical error that almost killed a patient.
According to the Los Angeles Times, medical staffers inadvertently left a towel inside his body after surgery. It stayed there for three months until the error was discovered.
The state report indicates patient was admitted to the hospital in April 2014 to undergo a surgery on his bladder and prostate. Everyone expects to feel a little rough after surgery, but the patient later told investigators he wasn’t getting better. In fact, as the weeks wore on, he got worse. He lost 43 pounds. His bowels weren’t working properly. He had no energy, no stamina. He later said, “I felt like I might not live.”
He returned to the doctor to report his growing list of symptoms. Doctors conducted a scan and found a large mass inside his body. He would need surgery. He feared it was cancer. However, what they discovered was a blue surgical towel that had been left behind during the earlier procedure.
At the time of the surgery, the hospital in question had a procedure in place for counting surgical tools during procedures. However, there was no procedure in place for counting those towels. Interestingly, immediately following the patient’s first surgery, he had to undergo an X-ray because there was a miscount of surgical scissors. Health care workers wanted to make sure the tools weren’t somehow left inside the man’s body. But the X-ray couldn’t detect the towel that was left behind, and so it stayed.
When the towel was discovered, the hospital described the surgical team’s reaction as “devastated.” The towels were only supposed to be used by surgeons when drying their hands after scrubbing in or to drape over a patient, but they weren’t supposed to be for use inside a patient. It’s still unclear how that happened. Now, following the conclusion of a state investigation into the incident, the hospital said it has changed its procedures to require surgical teams to keep count of towels in the operating room.
A report released in 2013 by The Joint Commission indicated some 800 people had suffered serious illness after surgical instruments left inside them from 2005 to 2012. Of those patients, 16 died as a result of the medical malpractice. In almost all cases, patients had longer hospital stays.
Incidents were nine times more likely to occur when the surgery was on an emergency basis and four times more likely when the surgery changed unexpectedly mid-procedure. Most common sites for such incidents were:
- Operating rooms;
- Labor and delivery rooms;
- Ambulatory surgery centers;
- Labs where catheters or colonoscopies take place.
The most common reasons it occurs are:
- Lack of policy and procedures;
- Failure to comply with existing procedures;
- Failures in communication with fellow doctors;
- Hierarchy and intimidation problems in hospitals;
- Poor education of staff.
The Joint Commission report profiled a case of a nurse from Kentucky who became violently ill one day, only to discover via CT scan that she was suffering the ill effects of a surgical sponge, which had been left in her body during a hysterectomy four years before. By that time, the sponge had adhered to the stomach and bladder tissue, and she had to undergo a series of painful operations. She still suffered lifelong disability, and was ultimately awarded $2.5 million.
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Fresno hospital fined for leaving towel in patient for three months after surgery, Jan. 29, 2016, Los Angeles Times
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